A holistic model of care that involves detailed interactions between nurse educators and individuals with a disease, has been found to nearly double the likelihood of significant improvement among depressed patients. In this team approach, a doctor’s office nurse monitors patients by phone and coordinates communication between medical and mental health providers.

Unfortunately, reimbursement for this treatment paradigm is often not available.

“Care management models for depression help more people get better,” said lead review author John Williams, M.D., of the Veterans Affairs Medical Center in Durham, N.C. However, the approach may not be practical for many care settings. Most of the reviewed studies were conducted in large health care organizations (HCOs, HMOs) and required additional resources or staff reassignment.

“Practices in fee-for-service environments that do not reimburse for care management services have few incentives for implementing these interventions,” the authors say.

Finding effective ways to treat depression is increasingly important because the mood disorder will be the second leading cause of disability in the developed world by 2020, according to the World Health Organization.

Experts are trying the doctor’s office-care manager approach because most Americans with mental illness are treated exclusively by primary care clinicians, not by a mental health specialist, studies show.

The review, which appears in the latest issue of General Hospital Psychiatry, includes 28 randomized controlled trials involving almost 11,000 patients, primarily in the United States and Western Europe. The majority of patients were white females, except for those in five studies based in Veterans Affairs medical centers and a study in Santiago, Chile.

Twenty studies resulted in patient improvements recorded for up to one year. Of these, three revealed that the benefits persisted for nearly five years. Patients reported better mental, social, physical and work functioning in the majority of studies that asked about these issues.

Core elements of effective care management programs include a registry of patients diagnosed with depression and a health professional who:

• educates patients about depression and encourages them to commit to specific treatment steps
• monitors each patient’s symptoms using a standard questionnaire
• tracks each patient’s treatment adherence
• consults with a mental health professional if symptoms or compliance needs improvement
• coordinates referrals to mental health specialists as needed

The studies also suggest that patients with different diagnoses may require different treatment approaches. Patients with major depression may benefit most from antidepressant drugs or psychotherapy and systematic follow-up by a care manager, the authors say. For minor depression, a period of “watchful waiting” before beginning treatment may be appropriate.

“Policy makers and health care organizations should promote [quality improvement] efforts that include well-trained care managers, patient support and education, longitudinal monitoring and decision support for medication management,” conclude the review authors.

Some major health plans are developing versions of these models, Williams said. These organizations include Kaiser-Permanente, Aetna, the Veterans Health Administration and the U.S. Army.

However, substantial obstacles remain, because physicians sometimes object to the approach. “There are some who feel the doctor-patient relationship is very special and don’t want it intruded upon by a third party like a care manager,” Williams said. Others, he added, welcome the team treatment strategy.

Institutional barriers also abound. “Putting these approaches into place requires a combination of clinical and economic systems strategies at multiple levels, engaging patients/consumers, providers, practices, plans and purchasers,” according to Jeanie Knox Houtsinger. She is deputy director of a $12-million national program — Depression in Primary Care: Linking Clinical and Systems Strategies — funded by The Robert Wood Johnson Foundation.

Developing mental health care standards and using pay-for-performance incentives for health care providers could play a great role in improving the quality of care for depression and other mental illnesses, Houtsinger added.

“Part of it is research,” Williams agreed, “figuring out a way to modify these models so that they can work in various settings. Then, researchers bring evidence to policy makers who influence reimbursement practices to make it easier to implement these models.”